Doctor did an exploratory laparotomy with partial minor pancreatic debridement with placement of intraoperative drain and abdominal washout and placement of abdominal wall Bard E/X mesh for abdominal compartment syndrome. The RVUs for 48105 are 71.26. Although the description of this code is as follows "Resection or debridement of pancreas and peripancreatic tissue for acute necrotizing pancreatitis" the RVUs seem high for what he actually did. Below is the op note. Any input is appreciated on coding this surgery.
DX:
1.Severe alcoholic pancreatitis, multisystem failure.
2. Abdominal compartment syndrome.
PROCEDURE FINDINGS: Significant amounts of intraabdominal ascites and very tense abdominal wall with marked abdominal inflammation without any evidence of abscess or purulent material. The lesser sac showed partial necrotic debris but no evidence of any liquefaction of the pancreas on blunt dissection:
PROCEDURE:
The patient was brought to the operating room after proper identification, confirmation, and PARQ. The patient was placed in the supine position. After adequate anesthesia, a generous midline incision was made, carried into the abdominal cavity. Upon entering the abdominal cavity, we initially noted that he began oxygenating much better due to the release of the intraabdominal pressure. We then explored the abdomen which was very tense throughout the whole abdominal cavity with the suction of approximately a liter of ascitic fluid. The bowel was then inspected with significant saponification and peritoneal irritation. The omentum was fairly inflamed and a partial omentectomy was done to allow entrance into the lesser sac.
Upon entering into the lesser sac we identified minimal necrotic tissue, but due to the acute inflammatory process it was very difficult to adequately and clearly identify the pancreas. Thus, the area was irrigated with copious amounts of normal saline and a 19-french round Blake drain was then placed into the lesser sac. The NG tube which had been very difficult to place previously after multiple attempts was clearly identified in the stomach and positioned correctly and taped into place. The previously placed abdominal drain was then removed, and a left upper quadrant drain was placed at the splenic flexure along the left pericolic gutter. The abdomen was then irrigated with copious amounts of normal saline.
The lower abdomen was inspected with no significant findings. Specifically, the appendix appeared to be normal. The bowel was run as best could be done due to the acute inflammatory process. A drain was placed in the pelvis. The drains were then secured into place with 3-0 nylon, and decision was made to close. Due to the preoperative diagnosis of abdominal compartment syndrome, decision was made to place a piece of Gore-Tex backed mesh in the abdominal wall. This was placed along the entire length of the incision which was 25cmx 15cm piece of Bard E/X mesh. This was sutured into place with running #1 PDS from each end of the incision to the middle on either side, loosely close to the abdominal wall. Prior to tying the sutures down the entire suture line was inspected for any signs of any bowel involvement. None was identified. The surface of the mesh and Gore-Tex backed mesh was clearly up to the anterior abdominal wall. Then, the decision was made to complete the surgery by tying the suture. A rolled up Kerlix was placed in the abdominal wall, opened, and then the entire incision was closed with an occlusive dressing.
Thanks for looking at this with me
Julie
DX:
1.Severe alcoholic pancreatitis, multisystem failure.
2. Abdominal compartment syndrome.
PROCEDURE FINDINGS: Significant amounts of intraabdominal ascites and very tense abdominal wall with marked abdominal inflammation without any evidence of abscess or purulent material. The lesser sac showed partial necrotic debris but no evidence of any liquefaction of the pancreas on blunt dissection:
PROCEDURE:
The patient was brought to the operating room after proper identification, confirmation, and PARQ. The patient was placed in the supine position. After adequate anesthesia, a generous midline incision was made, carried into the abdominal cavity. Upon entering the abdominal cavity, we initially noted that he began oxygenating much better due to the release of the intraabdominal pressure. We then explored the abdomen which was very tense throughout the whole abdominal cavity with the suction of approximately a liter of ascitic fluid. The bowel was then inspected with significant saponification and peritoneal irritation. The omentum was fairly inflamed and a partial omentectomy was done to allow entrance into the lesser sac.
Upon entering into the lesser sac we identified minimal necrotic tissue, but due to the acute inflammatory process it was very difficult to adequately and clearly identify the pancreas. Thus, the area was irrigated with copious amounts of normal saline and a 19-french round Blake drain was then placed into the lesser sac. The NG tube which had been very difficult to place previously after multiple attempts was clearly identified in the stomach and positioned correctly and taped into place. The previously placed abdominal drain was then removed, and a left upper quadrant drain was placed at the splenic flexure along the left pericolic gutter. The abdomen was then irrigated with copious amounts of normal saline.
The lower abdomen was inspected with no significant findings. Specifically, the appendix appeared to be normal. The bowel was run as best could be done due to the acute inflammatory process. A drain was placed in the pelvis. The drains were then secured into place with 3-0 nylon, and decision was made to close. Due to the preoperative diagnosis of abdominal compartment syndrome, decision was made to place a piece of Gore-Tex backed mesh in the abdominal wall. This was placed along the entire length of the incision which was 25cmx 15cm piece of Bard E/X mesh. This was sutured into place with running #1 PDS from each end of the incision to the middle on either side, loosely close to the abdominal wall. Prior to tying the sutures down the entire suture line was inspected for any signs of any bowel involvement. None was identified. The surface of the mesh and Gore-Tex backed mesh was clearly up to the anterior abdominal wall. Then, the decision was made to complete the surgery by tying the suture. A rolled up Kerlix was placed in the abdominal wall, opened, and then the entire incision was closed with an occlusive dressing.
Thanks for looking at this with me
Julie